Laparoscopic Sleeve Gastrectomy

Dr. Meireles expertly conducts the world’s most commonly performed bariatric surgery for weight loss in this JoMI production on textbook sleeve gastrectomies.

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Introduction

Port Placement

Biopsy Liver

Insert Liver Retractor

Sleeve Gastrectomy

Identify Anatomy

Dissect Greater Curvature of Stomach

Expose Left Crus and Gastroesophageal Junction

Staple and Transect Stomach

Remove Specimen with Endocatch Bag

Hemostasis and Closure

Gastroscopy

Test Staple Line for Leaks (Insufflation Under Saline)

Staple Line Hemostasis

Close Port Sites

Debrief

Transcriptions

Please note that, unless otherwise stated, these transcriptions have been auto generated and therefore we can not guarantee their complete accuracy.

CHAPTER 1

My name is Ozanan Meireles, and I’m a bariatric minimally invasive foregut surgeon at the Massachusetts General Hospital. I’m an assistant professor at Harvard Medical School and the case are going to be doing today is a - the most performed bariatric procedure performed in the world right now which is laparoscopic sleeve gastrectomy. Actually the name is laparoscopic partial vertical gastrectomy. We say sleeve because the gastric cone that's created looks like it's a sleeve but we're putting no foreign body on this procedure.

The procedure takes about an hour and is performed in such a fashion where we separate the stomach from its adjacent ligaments both freeing up the greater curvature and the fundus, exposing the left crus, identifying the gastroesophageal junction. And then, once that dissection is performed, we’ll be tailoring the - the gastric colon to be the same caliber of the esophagus which some surgeons prefer to use Bush's, others prefer to use gastric scopes, but in my personal experience, having a gastric colon that’s the same caliber as the gastroesophageal junction both prevents post-op reflex, dysphagia, and weight regain. I’m anticipating this case is going to be as standard as possible and that's it.

CHAPTER 2

So knife. Syphoid. Remember, we were talking about this the other day - if y'all don't want to see this one - feel here. It’s not at the tip of the xiphoid is right in the angle - yeah, but the complaints were here. Okay. Incision. Thank you.

Alright, so let's have the - let’s turn the gas on. Fantastic, okay. Perfect. Will you stabilize the port for me like this - thanks. So this case is being done in French position actually - that's my preferred way to do foregut surgery. Cuz the surgeon’s going to be aiming towards through the Atari. That's going to be right here in a hiatus. Kick out splitter lags or French position, but it's just a different way to do advanced foregut laparoscopy.

Hold this for me please. Knife. So hold it right here. Knife. So then, the fossa form’s a little big here, so we going to go... See, right here. The alligator. Sorry I’m doing a liver biopsy right now. Yeah, I think. You got it. Nice. Lovely.

Knife please. So the reason I got three time - I don’t think I ever told you - the muscles here collapses back very easily. Like now for example. I already lost my - there you go. So much better. And so you put them on a diet of like? About 2 weeks on a low calorie, high protein - the idea is because the very first organ to decrease in size when you start losing weight is the liver cause almost like half of the weight of the liver storage is glycogen. Yeah. So let's put patient in reverse t burg, and put the lights off.

CHAPTER 3

So umm - what happens is, as you are suddenly running out of a glucose - right - and you need to generate glucose so that goes through the liver storage first. Likewise if you're gaining weight, the very first organ that increases in size is the liver.

So this is a standard liver gastrectomy patient. We can see the anatomy here. That's the lesser curvature here. That's the greater curvature here. And that's we're going to be allies - we’re going to be allies the gastrocolic ligament from here, all the way up - and then we’re going to be taking down the gastrosplenic ligament with the short gastric vessels. And then finally, then the Angle of His which is there to free up the entire stomach. Then we'll be dissecting - remember - the valgus fat pad to expose a gastroesophageal junction. Of interest, this is the - where is the pylorus. And that’s where the antrum being. so everything from here over there is the antrum - we’re going to try to preserve.

So, we start going contralateral of the incisura angularis. Perfect. So, lift it up a little bit more. So, this in omentum. And this is gastrocolic ligament. See - you have a good angle there. Do you want the table down a little bit? Can I have the table down a tad? The other way - the other way - facing the curvature, facing the stomach. So, right here? Perfect. Is that good, or would you like more? Open wider - that’s good right there. Now open wide and push it in. There you go. So I like this technique to enter the lesser sac, cuz what we’re doing is we're pulling the gastrocolic ligament up in the stomach, and as we do this, without actually breaching through our cut right here - see this is already open, could potentially go inside, but I prefer to keep going. Push it in. There you go.

So then we do dissection both cranially and caudally, and it saves a lot of time. Of course, you have the luxury of the stomach coming out, so can you go pretty close to the stomach. I’ll feed that - I’ll feed that for you - hold - hold closer to the stomach. There you go. Closer. Okay, let’s see if we can go one more. Lift it up in your hand - left hand. Okay. Active blade facing in. No - no - you have a vessel - there you go. Take another one. So let me regrab - let go. Do me a favor - just, see that tiny little red area over here - just get a tiny little bite of the harmonic there. If I have a good angle or not. Let’s see here. Yep. You got it. Close it. Perfect. Okay, good. Bring it up. So let’s get one more bite, but let’s go away from the stomach. Open wider. Pull away from the stomach as you do this. Okay, that’s fine. So, just one more bite here, away from the stomach. Close to my instruction. There you go. Now lift it up and away from the stomach as you pull it - fast. Okay, good. Alright, perfect.

So now, let’s go proximally. Close - see the vessel is about to bleed right there. Okay. Nice. Lift it up as you do this. Okay, so what's going to happen is - hold this - and you and I are going to be bringing our target over here so you can have a better angle for the harmonic. Lift it up. There you go. Okay so what happened is - so then, let’s do this - let’s move it to the left - there you go. Fast. And the quickest you go through this part and get to the best angle for the surgery, you stop suffering - well not suffering - struggling.

Yeah, so let’s do this. Yeah. We’re going to reposition the liver retractor if you need it, but you're going to be getting out of this pretty soon, so. Let me see one thing here. So, what’s going to happen is that’s going to be the angle we’re going to be operating, so it looks pretty good for me from here. So if we need to move the structure in more over there, we do that, but there's no need to reposition this right now. Fast. If it’s transparent, go fast. Now slow down. See, it’s getting much better, isn’t it? See, for a laparoscopy, you can never have like a hundred percent perfect port placement for all the steps of the operation, so you just say for the most critical ones.

Okay, get this vessel first. Actually, right there, that’s the take off of the left gastroepiploic. Another take off - but when it starts - you go all the way over here for the - yes cancer operation that's going to be resected - entire length. Okay, now keep pulling more with left hand. That’s the Angle of His right there. That’s the gastrophrenic ligament which makes the Angle of His. I’m going to check in a min - right now. Just keep going - since we’re making progress. Pull with left hand - to hold right here. So let's just open this layer of protein here - small bite - fast. Nice. Push it in - you’re going to feel it. You’ll be tractioning with your left hand. You’ll be tractioning a lot. So hold right here. So lift it up a little bit.

So those are the phrenics right here, so let's be careful. So once you engage your blade right here between the stomach to the left and lift it up and get all of this in one single bite. No - no - don't get the phrenics. Push it in. Okay - lift it up, fast. Nice - good. Careful. Careful. Careful. So let’s get a bite right here. Let me just. Fast. Alright, it’s looking better here, so hold this. Actually, more posteriorly - hold right here. Hold the 3-0-G right there. Let’s just make it - if I could - the stomach first. Let go for a second. Hold this pull to the left. Hold right here. More to the left. There we go, so what we’re going to do is kinda focus this on it. There you go. Fast. Nice. Careful - good - close to the stomach. And that part’s probably going to stay. So a little bit away from the stomach. Okay, good.

Bite - push all the way through next to my instrument. You can get a better bite - push all the way through. I want you to feel the crus right here. It’s a length right there, grab a bite. No - see what’s bleeding right now? Let’s get a big bite right there. This is nothing. So where I go - I want you to see the decussation of the crus is here. So what I want you to do is you get your blade right here, between what are going to be holding the lymph nodes. Push all the way through - to the right - you are going to be all way from the stomach and this part I’m going to stay. Okay. That’s the crus. So we’re pretty much done. Do you mind if I take the vessels? No. Okay, perfect.

So what I'm dissecting right now is the - what we call the valgus fat pad. Then expose the gastroesophageal junction so they're going to show me what’s the gastroesophageal caliber so I can actually calibrate the sleeve. The gastric cone. See right here. Alright Julie, this is nothing. Alright, let’s take a look. I so can see the esophagus - let me see - you can actually see the phrenoesophageal ligament going into the camera. Camera up and to the left a little bit. So what I want you to do is grab this fat for me. Camera up a little bit.

That’s where the phrenics - let go. Okay, it’s right there on the bottom. Okay. See here. Show me the - he’s kinda bleeding a little bit there. Can I have a metal clip please? So if you ever think that a phrenic artery may bleed, you got to do something - okay - cuz that’s the first branch of the intra aorta and that’s a lot of pressure right there. It’s sharing kinda the supply of the artery, so we need to take this now. Keep traction to the right. Hold on - let me just. Right here - pull more. Traction away. Pull - pull. Okay, perfect. So let's see here. Okay, there we go, that’s the phrenoesophageal ligament. So now we see the phrenoesophageal ligament over there. We know this is the esophagus. Let’s take a look at the phrenics - we’re going to put clips on it. If you hold that - that one? Yeah. I was going to transect it cuz otherwise it becomes fat necrosis. Pull that.

So I think we are ready for stapling. I’ll take a look at the dissection - see how far you got. Let’s go all the way down here. Looks pretty good, okay. Alright so let's drop the scope, yeah? And Julie take a clean right tag please and a stapler. Hold this - thank you. Camera up. Looks good over there. Looks good over here as well. Alright. So the first fire is parallel to the incisura angularis. So that’s why I chose that point.

Okay, Julia, ready for you. Perfect, yeah. Let me see the light. Perfect. Excellent. You can park the scope there and come back. And then what I’m doing now - I’m aiming my stapling towards to the gastroesophageal junction right there. Nice view here. Julia, can you appreciate the difference on the fibers? And do you remember like when we’re doing the POEM, we talk about the vessels? Those are the vessels we’ve already seen. See that, yeah. See that pattern of them - the molar institution over here - was in the stomach - they changed there. Alright, stapler.

So we’re going to be holding underneath here - going to go underneath your - stomach’s not as big as - pull this. You’re good. Push it in. You’re going to be pulling it to the right. Flatten your stapler. So, get it flat. Okay, you’re pulling, right? So slide - slide your stapler to the left a little bit. Push it in. Slide - a little bit to the right - like a millimeter right. Just rotate to the right a little bit. Perfect. Let’s see here, push it in. Start closing very slowly. No actually, I want you to be to - it’s going to be two millimeters to the right. Yeah. Let’s see. Start closing. Yes. Perfect. Alright.

Beautiful. Another - another staple - 6 is fine. See the angle makes a difference here - see if you actually had angle, what's going to happen is, it will start getting wider. Push it in. Yeah - I like that. Good, let’s see. Shall we close right there? Stop - just for a second. So lower your stapler just a little bit so I can grab this - okay good. Finish closing. Perfect. You can go faster - the tissue is thinner so. Wait wait - there you go. Perfect. Alright. Let’s move the grasper there. Looks beautiful. Hold that. Perfect. Endocache bag.

So lower that - get it - get it facing us, so I can grab it. Well, you got to get it to face us. Alright, start closing it. Slow down a little bit. Alright. Perfect. Alright, let me see the specimen. Tell me. Alright. You’re not going to like this either. Perfect.

CHAPTER 4

Alright, so I'm going to do the endoscopy right now if you guys can hold the ET tube please. Alright, so we’re going to start insufflating. Pulling back. Antrum. Incisura looks great. Straight tube. Brazil line right here looks good - perfect.

I’m going to need a few spots here. So pull it away - bring it towards the camera. Perfect. There you go. One right there. Nice. Keep holding it. One more Julie. Let’s put one right there - in the middle. There you go. Good. One right here. Looks good. Looks good. Looks good. Let’s go looking back here. Let’s just put one adjacent to it. To the right dot - right there. It’s good. Perfect. Alright, good. We’re done. Perfect. We’re done with the case. You guys can go ahead and level the patient please. Sure!

O-4 for us please.

CHAPTER 5

So that was - that was the end of the case. There was a standard partial vertical gastrectomy, or is also called sleeve gastrectomy. There was no hiatal hernia. There was no adhesions. There was no prior surgery. So it went as expected. Like, normally those cases take less than an hour like this one. Ah, we always do an intraoperative endoscopy - look inside the new lumen how it looks - it should look straight - the antrum is preserved - no narrowing of the incisura - the tube is the same caliber as the esophagus, and that's what we go from this case. So it couldn’t be more straightforward, this one.